Population health, as defined by Kindig and Stoddart (2003), is the health outcome of a group of individuals, including the distribution of such outcomes within the group. It is widely viewed as an opportunity for healthcare organizations and health insurance companies to collaborate and work in synergy to improve the health outcomes of the communities they serve and abridge any inequalities among population groups. Health outcomes of populations are determined by various factors and categorized as social, environmental, behavioral, genetic, other healthcare and physical factors.
Population health will become a top priority for the healthcare providers and payers as the industry is facing a paradigm shift to adopt changing regulations, reduce costs and provide better quality healthcare. The correct proportion of technology and techniques determines the success of population health management. Listed below are the phases of the sequential approach that organizations can follow to achieve effective and holistic population health management:
- Data collection. Data collection forms the foundation in a population health initiative. Electronic Health Records (EHRs) act as huge repositories for patient data. With the help of advanced analytics tools, the data gathered during the treatment of a health condition can help in identifying the gaps in care delivery. Also, by combining the patient data with the claim data, a comprehensive 360 degree view of the patient health can be obtained.
- Risk stratification. Risk stratification is the next step which helps in identifying the patient groups or patient population based on their health and risk exposure. Risk stratification helps in grouping the patient population into different categories such as healthy, at-risk, affected, etc. Once the categorization is identified, care providers can apply specific strategies to intervene and mitigate the health condition. This ability to stratify risk saves time, energy and money for all organizations involved in the entire continuum of healthcare delivery.
- Care plan. Once the risk groups are identified, care organizations can arrive at a plan to address the specific condition. This care plan is further customized to the needs of the specific patient population. For example, the care plan will be different for patients who are at risk from those who are affected by the same health condition. This offers better and quicker results, and also addresses the chronic health conditions at source. There are various technological tools which can aid in arriving at the care plan.
- Patient self-management. Self-management by patient can go a long way in making population health program a successful one. It consists of various actions to be taken by the patients for their own health and well-being. Self-management involves various steps which are often simpler, but can offer a great deal of results on the overall health of the patient. Effective self-management forms a critical component in reducing the risk of chronic diseases such as Diabetes.
- Monitoring and evaluation. Continuous monitoring is an integral component in any successful population health initiative. Continuous monitoring and evaluation of patients help in reducing the need for multiple hospital visits which are often costly and time consuming. It can be offered in a variety of ways and with the advanced technological gadgets like the fitness bands, care providers can monitor the vital parameters of the patients and evaluate the progress and apply different strategies for improved health outcomes.
The healthcare landscape is changing with a focus on patient-centricity and providing affordable, timely and quality health outcomes. The population health initiative is a step in that direction of transforming the healthcare industry. Its success will depend to a large extent on how the various stakeholders in the healthcare ecosystem are able to play their role effectively.